BlueCard

Ancillary Claims - Reminder

Effective October 14, 2012, Blue Cross Blue Shield of North Dakota (BCBSND) will deny claims for ancillary services filed to the incorrect plan.

Generally, health care providers file claims for Blue Cross and Blue Shield patients to the local Blue Plan. However, in unique circumstances, claims filing directions differ based on the type of provider and service.

Ancillary providers are Independent Clinical Laboratory, Durable/Home Medical Equipment and Supplies, and Specialty Pharmacy providers. The local Blue Plan for ancillary services is defined as follows:

Independent Clinical Laboratory (Lab) - The plan in the state where the specimen was drawn.

Durable/Home Medical Equipment and Supplies (DME) - The plan in the state where the equipment was shipped to or purchased at a retail store. "Shipped to" takes priority over where the equipment was purchased. The Place of Service (POS) will identify where the claim should be filed:

Specialty Pharmacy - The plan in the state where the ordering physician is located.

This policy does not apply to the Federal Employee Program (FEP).

Provider Type

How to file (required fields)

Where to file

Example

Independent Clinical Laboratory (any type of non hospital based laboratory)

Types of Service include, but are not limited to:

Blood, urine, samples, analysis, etc.

Referring Provider:

  • Field 17B on the CMS 1500 Health Insurance Claim Form or
  • Loop 2310A (claim level) on the 837 Professional Electronic Submission

File the claim to the Plan in the state where the specimen was drawn

Where the specimen was drawn will be determined by which state the referring provider is located.

Blood is drawn in a lab or office setting located in North Dakota. Blood analysis is done in Minnesota.

File to: Blue Cross Blue Shield of North Dakota.

Claims for the analysis of a lab must be filed to the Plan in the state where the specimen was drawn.

Durable/Home Medical Equipment and Supplies (D/HME)

Types of Service include, but are not limited to:

Hospital beds, oxygen tanks, crutches, etc.

Patient's Address:

  • Field 5 on the CMS 1500 Health Insurance Claim Form or
  • Loop 2010CA on the 837 Professional Electronic Submission

Ordering Provider:

  • Field 17B on the CMS 1500 Health Insurance Claim Form or
  • Loop 2420E (line level) on the 837 Professional Electronic Submission

Place of Service:

  • Field 24B on the CMS 1500 Health Insurance Claim Form or
  • Loop 2300, CLM05-1 on the 837 Professional Electronic Submission

Service Facility Location Information:

  • Field 32 on the CMS 1500 Health Insurance Form or
  • Loop 2310C (claim level) on the 837 Professional Electronic Submission.

File the claim to the Plan in the state where the equipment was shipped to or purchased in a retail store. The "shipped to" location takes priority over where the equipment was purchased.

Example: If the equipment is purchased in Minnesota and shipped to North Dakota, file the claim to North Dakota.

If the equipment is purchased in Minnesota and the member leaves the retail store with the product, submit the claim to the Minnesota plan.

A. Wheelchair is purchased at a retail store in North Dakota. File to: BCBSND

B. Wheelchair is purchased on the internet from an online retail supplier in Minnesota and shipped to North Dakota.
File to: BCBSND

C. Wheelchair is purchased at a retail store in Minnesota and shipped to North Dakota.
File to: BCBSND

D. Wheelchair is purchased at a retail store in Minnesota and the member leaves the store with it.
File to: Minnesota

Specialty Pharmacy

Types of Service:

Non-routine, biological therapeutics ordered by a health care professional as a covered medical benefit as defined by the member Plan's Specialty Pharmacy formulary. Include, but not limited to: injectable, infusion therapies, etc.

Referring Provider:

  • Field 17B on the CMS 1500 Health Insurance Claim Form or
  • Loop 2310A (claim level) on the 837 Professional Electronic Submission

File the claim to the Plan in the state where the ordering Physician is located.

Patient is seen by a physician in North Dakota who orders a specialty pharmacy injectable for this patient. Patient will receive the injections in Arizona where the member lives for 6 months of the year.
File to: BCBSND


Posted on: 8/28/2012